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April 21, 2010

Welsh Institue of Health and Social Care Blog
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» The Yanks are still coming

Having just returned from a holiday in the USA it was interesting to read David Hands’ blog about President Obama’s health reforms. Those of us brought up with the virtues of the Welfare State running through our veins find it astonishing that such a large body of American opinion should oppose enabling an additional 40 million American people to access health care. One news story I picked up in Florida was of a doctor placing a sign in his surgery saying supporters of Obama were not welcome. He later said that he was merely making a point and would not, of course, have turned any of his patients away!

My immediate reaction to the US health care debate was to conclude that the political ideology which underpinned the thinking of Obama’s opponents was so distant from mainstream thinking in this country that everyone would be as surprised as me that there should even be a debate. A bit naïve and idealistic perhaps but my way of offering my own personal vote of confidence to our National Health Service. Then I watched the first Prime Minister television debate and began to reflect on how much we have been influenced by the American way, or certainly American initiatives, in the last 30 years or so.

Here are some of the examples which came to mind. Out of town retail parks; Macdonalds and other fast food outlets; deregulation of public transport and the growth in car use; 24/7 opening hours; Starbucks and other coffee houses; 24/7 news coverage; 4×4 trucks; the internet; mobile phones; the growth in commercial television; and the acceptance of a whole new way of spelling our language, epitomised by the acceptance that it is ok to spell it ‘epitomized’. We could have a poll on which are good and which are bad, which we like and which we don’t, but the truth is that all these things, and others, are here to stay.

The worry I have is that I think a tacit acceptance that ‘what America does today, we should do tomorrow’, has crept into our culture and if this is allowed to run its ultimate course it would lead to the demise of the NHS, the BBC and any other institutions which were based on the notion that the collective good is more important than the individual. The first TV election debate summed this up perfectly. It was all about which of the 3 party leaders could impress us more, not which policies would produce the best way forward for our country. The fact that they are representatives, albeit leaders, of their parties seemed to be lost. It was described by some journalists as the most public job interview in history. It was an American presidential debate superimposed on a British political system.

Personally, I thought the first debate was a dispiriting event and, again naively perhaps, find it offensive and concerning that voters should be influenced by the colour of a suit and tie, the degree to which you looked down the lens of the camera, and your ability to tell a joke, all of which featured in the post-debate analysis. Interestingly, Karen Lewis’ blog on the 15th April about the richness of storytelling as a means of understanding real issues was in sharp contrast to the universal opinion of the political journalists that the 3 leaders had all been guilty of overdoing the anecdote, typified by ‘a cancer patient in wherever was telling me last week that he couldn’t get the right drug because….’.

We are yet to see, of course, whether the TV debates will actually lead to changes in voting but we should all be concerned that 90 minutes of television, which covered no more than 8 questions, all relating to home policy, can lead to such dramatic movement in opinion polls. We are told that there is now no going back and that the debates will now be a permanent feature in Parliamentary elections. And if you think I’m overstating this Americanisation theory, have a look at the way all the parties seem to be supporting the introduction to Charter schools which many believe represent the potential end of our state schools.

I’m sure if Alistair Cooke was still alive and presenting his ‘Letter from America’ we would all be listening in carefully to find out what we’ll be doing differently in the next few years.

Written by Tony Garthwaite, WIHSC Senior Fellow

April 7, 2010

Welsh Institue of Health and Social Care Blog
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» A Mighty Leap for the USA?

The passage of the US healthcare bill is undoubtedly a major political triumph for President Obama. By 2019, almost all Americans will, at last, be covered by almost comprehensive health insurance. In the US context this is undeniably a major step forward. However, in terms of global national health system development, this brings the USA to something like the stage reached by the leading European nations a century ago.

Ideological imperatives inevitably forced the US President to extend existing insurance-based arrangements rather than attempt more radical alternatives. Unfortunately, whilst the extended arrangements are to be welcomed, insurance is a shaky foundation for covering health risks.

The general principle of commercial insurance is to decline to cover any risk which seems likely to occur. This is why, in the USA, those with dubious or uncertain health histories have been refused cover (or priced out of it) and why women (who are judged to be higher risk) frequently have to pay higher premiums.

Group insurance, particularly that provided by employers, has also proved to be unreliable. For example, it has been estimated that, in 2008, more than a million Americans lost their health insurance when they lost their jobs in the recession.

Insurance-based systems are also expensive to run. Commercial insurers will only cover high risks if they are guaranteed a government subsidy. The costs of running and policing a system based on individual payments and claims are high. These and associated costs have been estimated to absorb as much as 40% of health expenditure in the USA.

Even the best insurance cannot guarantee access to services when they are needed. The ‘health gaps’ in some states have been described as “shockingly wide”. For example, in some rural states, doctors are thin on the ground. Infant and maternal mortality rates approach third world levels in some areas. Apparently, in Montana, the average emergency response time is eighty minutes. Financial coverage is only the beginning: it needs to be matched by comprehensive planning and provision of services.

In reality, for most people, ill-health is a certainty, not a risk. Inevitable life events are simply not insurable on commercial terms. This is why most other developed nations have introduced more cost effective and equitable systems of service entitlement based on citizenship. These involve either government sponsored, non-commercial insurance or, in the case of the Nordic countries and the UK, tax-funded arrangements which cut out the middle man entirely. They also involve better planning of services on the ground.

So, well done Mr President! Now for the real challenge!

Written by Professor David Hands, Visiting Professor

February 11, 2010

Welsh Institue of Health and Social Care Blog
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» Public services really are better!

As the Assembly seeks new legislative powers and as the general election approaches, is there still time to build the new Jerusalem somewhere along the M4?

Wales has eschewed much of the New Labour agenda as its fledgling Assembly increased in strength and bathed in clear red water. Within the NHS the use of market forces as a deliberate tool of policy to spur efficiency has been read the last rites as the new Health Boards come into being. NHS Wales is not in hock to expensive PFI schemes. Even England is now thinking of scrapping hospital car parking charges.

Obama struggles against the power of vested insurance and other interests in the USA as enough of that country continues to believe that Government is “bad” and individual freedom is “good”. Financial institutions have been seen to have no clothes as the complicated financial instruments which they invented and sold have managed to transfer wealth from the poor to the rich whilst simultaneously mortgaging the future earning power of most economies for the next decade. All this from a creed bowing before the wisdom of the market. “Wise” bankers who created the mess command millions “because they’re worth it” while the genial Terry Wogan’s daily army of 7 million TOGS seemingly cannot justify his more modest BBC fee just because it is paid by a public body acting for us all.

Is it too much to ask that the NHS – the antithesis of marked-based approaches to creating and distributing one form of wealth (personal and collective health) – should continue to show that an alternative creed can, and does make sense? Is it hoping for too much to expect the new Welsh Health Boards to cherish the Welsh tradition of solidarity that spawned the NHS and re-invent it for the 21st century? And is it still a good thing to have public services staffed by people whose worth and “output” is judged by the good they do, rather than by the price some arcane system of mathematics places on the few bits of healthcare it thinks it can value?

Tony Beddow, Visiting Professor, WIHSC